Assessment 49 year Pulmonary function No comorbidity Septic shock - - PDF document

• 49 year
• No comorbidity
• Septic shock and ARDS after abdominal

surgery for necrotising appendicitis

• ICU admission for 33 days
• ECMO (6 days) – MV (26 days) - CVVH
• Status 2 yrs after hospital discharge
• Clinical symptoms: general fatigue, weakness,

unemployement, impaired quality of life

Case: Mrs S.

Assessment

Pulmonary function Maximal exercise testing (incl ECG, respiratory gas exchange, ventilation) Functional exercise testing Muscle testing Quality of life Physical Activity

Quality of Life

• SF 36
• Physical component: 37 (vs 55 reference population)
• Mental component: 25 (vs 58 reference population)
• Beck Depression Inventory (II) scale:
• Total score 42: severe depression

Lung function FEV1 FVC FEV1/FVC TLC TLCO Measured 2.11 L 2.53 L 83% 3.70 L 5.03

mmol/min/kPa

% pred 88 90 81 65

Age 48yr BMI 32,1

Pulmonary function

Questions?

• Is this patient a good candidate for an exercise training

program?

• Are there limitations to perform an exercise training

program?

• Are you able to prescribe a detailed exercise training

program with the present information?

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EXERCISE TESTING

What information is searched for?

• Is the exercise capacity limited (compared to age-

matched healthy subjects)?

• Which are the limiting factors?
• Is maximal exertion safe?
• What is the appropriate exercise intensity during

training?

à Maximal exercise testing!

Wmax VO2max HR VE MVV Sat Rust/max Borg Dyspnea/Fatigue- Exertion 6MWD 90 W 1.24 L/min 15,1 ml/kg 151 min-1 54 L/min 79 L/min (37,5x 2.11 (FEV1) 97/97 % 7/8 335m 92 %pred 77 %pred 88 %pred 68 %MVV 62 %pred

EXERCISE TEST

• Is the exercise capacity impaired?
• YES (VO2peak ~ 75%pred, 15mL/min/kg, 6MWD 62%)
• Which are the limiting factors?
• Cardiovascular: (HRmax /HRmaxpred: 151/172 (+/-10)) NO/YES
• Ventilatory (VEmax/MVV: 54/79=68%) NO
• Gas exchange limitation (SaO2 rest/exerc 97/97%) NO
• Muscle weakness (Fatigue score of ´7´ is indicative, but muscle

strength tests are needed)

• Other? (additional information not from exercise test,

comorbidity?)

• Is maximal exertion safe? (no ECG abnormalities reported)

Muscle Strength PImax Quadriceps Handgrip Shoulder Abd Measured

• 124 cm H2O

139 N 20 KgF 130 N % pred 136 35 71 86

Treatment

• Which treatment modalities?
• Which modality of exercise training?
• Strength training?
• Other modalities: respiratory muscle

training?

FUNCTIONAL ASSESSMENT

Training schedule

• Cycle ergometer (Wmax: 90 Watt):
• Start training intensity (load): 60%Wmax: 55Watt
• Treadmill walking (6MWD: 335m)
• Start training intensity (speed): 75% 3.35km/h: 2.5 km/h
• Stair climbing
• Start training: 2 min at self-selected pace (Borg scale 4-6)
• Resistance training (1RM: 40kg)
• Start training intensity (load): 70%1RM: 28kg)
• Arm crancking
• Respiratory muscle training?

WEEK DURATION INTENSITY 1 10 min. 60% Wmax 2 12 min. 60% Wmax 3 12 min. 65% Wmax 4 14 min. 65% Wmax 5 14 min. 70% Wmax 6 14 min. 70% Wmax 7 14 min. 75% Wmax 8 16 min. 75% Wmax 9 16 min. 80% Wmax 10 16 min. 80% Wmax 11 16 min. 85% Wmax 12 16 min. 85% Wmax

Example Endurance Cycling Program

WEEK DURATION INTENSITY 1 10 min. 75% Speed MWD 2 12 min. 75% Speed MWD 3 12 min. 80% Speed MWD 4 14 min. 80% Speed MWD 5 14 min. 85% Speed MWD 6 14 min. 85% Speed MWD 7 14 min. 90% Speed MWD 8 16 min. 90% Speed MWD 9 16 min. 95% Speed MWD 10 16 min. 100% Speed MWD 11 16 min. 100% Speed MWD 12 16 min. 110% Speed MWD

Example Endurance Walking Program

WEEK INTENSITY SERIES- REPETITIONS. 1 70% 1 R.M. 3 x 8 2 70% 1 R.M 3 x 8 3 76% 1 R.M 3 x 8 4 82% 1 R.M 3 x 8 5 88% 1 R.M 3 x 8 6 94% 1 R.M 3 x 8 7 100% 1 R.M 3 x 8 8 106% 1 R.M 3 x 8 9 112% 1 R.M 3 x 8 10 115% 1 R.M 3 x 8 11 118% 1 R.M 3 x 8 12 121% 1 R.M 3 x 8

Example Peripheral Muscle Resistance Training Program

Muscle Strength PImax Quadr Hand Shoulder Abd Measured

• 124 cm H2O

139 N 20 KgF 130 N % pred 136 35 70 86

Respiratory muscle training?